Preventing death and disability through the timely provision of prehospital trauma care

Injury remains a major cause of death
and disability worldwide, and places
an enormous burden on countries with
limited resources. The optimal way
to reduce life-threatening injuries is
through primary prevention efforts that
decrease the incidence and severity of
injuries. When prevention fails, however,
it is often possible to minimize the
consequences of injury through effective
pre-hospital and hospital-based trauma
care.

Unfortunately, much of the world’s
population does not have access to
pre-hospital trauma care, particularly in
low income countries. In many parts of
the world, few victims receive treatment
at the scene and fewer still receive safe
transport to the hospital in an ambulance.
Transport, when available, is
usually provided by relatives, untrained
bystanders, commercial drivers (minibus,
taxi or truck drivers), or by public
safety officers (police and firefighters).

Many high-income countries have
developed technically complex and
costly pre-hospital trauma care systems
to provide care for acutely ill or injured
patients. While these systems are impressive
and they undoubtedly benefit
some patients, there is little evidence
that they are inherently superior to less
costly systems that provide a more basic
level of pre-hospital care. The start-up
and maintenance costs of advanced life
support systems place them out of the
reach of all but a few countries, effectively
eliminating them as a practical,
sustainable option in many parts of the
world. Expensive systems are not necessarily
the best. With few exceptions,
most advanced pre-hospital interventions
have not been scientifically proven to be
effective because the necessary randomized
trials have not been conducted.

In fact, most of the benefits of
pre-hospital trauma care can be readily
realized if basic, vital interventions are
quickly and consistently applied, utilizing
a country’s existing resources and
health-care infrastructure. Considerable
good may be accomplished by ensuring
that victims receive life-sustaining care
within a few minutes of injury. Even
in countries with limited resources,
many lives may be saved and disabilities
prevented by teaching individuals what
to do at the scene of an injury. The
foundations of an effective pre-hospital
system can be laid by recruiting carefully
selected volunteers and non-medical
professionals, and providing them with
training as well as the basic supplies
and equipment they need to provide
effective pre-hospital care. Most severely
injured patients who die in the first
few hours after injury succumb to airway
compromise, respiratory failure or
uncontrolled haemorrhage. All of these
conditions can be treated using basic
first aid measures.

The challenge, however, is to
promote sustainable and affordable
pre-hospital trauma care systems that
provide services to everyone. To do this,
each system must be defined by local
needs and capacity and must be developed
with due regard for local culture
and health-care capacity. To facilitate
the system’s adoption, members of
the community being served must be
directly involved in developing and administering
it, and initial infrastructure
development should focus on identifying
those responsible for administration,
system design and legislative development,
addressing political concerns and
economic considerations. It is not easy
to invest in and maintain a pre-hospital
care system: competing priorities in
budgets may make it difficult to secure
adequate funding. Although pre-hospital
systems that rely on volunteers are not
unique, system planners may want to explore
the provision of financial or other
incentives for providers. Additionally,
the absence of cost-recovery mechanisms
may further complicate the issue. Stakeholders
may want to consider innovative
strategies for generating resources, such
as dedicating a proportion of highway
budgets, allocating a portion of vehicle
registration fees or traffic penalties, or
levying a fuel tax.

Two WHO publications assist decision-makers faced with the challenge of developing trauma care systems in low and middle income countries. Guidelines for essential trauma care (1) addresses hospital-based trauma care, while Pre-hospital trauma care systems (2) focuses on injury care in the pre-hospital environment before the patient reaches the hospital, recognizing the role of simple, basic, cost-effective systems; it provides a global overview of system development and recommendations for countries with no pre-hospital care system in place, as well as mechanisms to strengthen care in countries with existing pre-hospital care systems.

The global burden of injury is immense.
Policy-makers can reduce the
human and economic toll of injuries by
implementing basic, simple pre-hospital
trauma care systems. Any pre-hospital
care system, no matter how narrowly
defined, will also be called upon to
respond to all types of medical, obstetric
and paediatric emergencies. When these
pre-hospital care systems are linked to
a country’s existing public health and
health-care infrastructure, they can
substantially enhance access to care,
augment a country’s capacity to care for
a wide range of emergency conditions,
identify opportunities for prevention,
and strengthen a country’s disaster
response capacity.